Preoperative Congestive Heart Failure Is Associated with Higher 30-Day Myocardial Infarction and Pneumonia after Endovascular Repair of Abdominal Aortic Aneurysm.

INTRODUCTION: Preoperative congestive heart failure (CHF) is associated with higher postoperative mortality and complications in noncardiac surgery. However, postoperative outcomes for patients with preoperative CHF undergoing endovascular aneurysm repair (EVAR) have not been thoroughly established. This study evaluated the effect of preoperative CHF on 30-day outcomes following nonemergent intact EVAR using a large-scale national registry. METHODS: Patients who had infrarenal EVAR were identified in the ACS-NSQIP database from 2012 to 2022. A 1:5 propensity-score matching was used to match demographics, baseline characteristics, aneurysm diameter, distant aneurysm extent, anesthesia, and concomitant procedures between patients with and without preoperative CHF. Thirty-day postoperative outcomes were examined. RESULTS: 467 (2.84%) CHF patients underwent intact EVAR. Meanwhile, 15,996 non-CHF patients underwent EVAR, where 2,248 of them were matched to all CHF patients. Patients with and without preoperative CHF had comparable 30-day mortality (3.02% vs. 2.62%, p = 0.64). However, CHF patients had higher myocardial infarction (3.02% vs. 1.47%, p = 0.03), pneumonia (3.23% vs. 1.73%, p = 0.04), 30-day readmission (p = 0.01), and longer length of stay (p < 0.01). CONCLUSION: While patients with and without preoperative CHF had comparable 30-day mortality rates, those with CHF faced higher risks of cardiopulmonary complications. Effective management of preoperative CHF may help prevent postoperative complications in these patients.

Preoperative anemia is a risk factor for worse 30-day outcomes in both open and endovascular repair of non-ruptured infrarenal abdominal aortic aneurysm.

BACKGROUND: Anemia is a highly prevalent condition potentially linked to chronic inflammation. Preoperative anemia is an independent risk factor across many surgical fields. However, the relationship between anemia and abdominal aortic aneurysm (AAA) repair outcomes remains unclear. This study aimed to examine the effects of preoperative anemia on 30-day outcomes of non-ruptured infrarenal AAA repair. METHODS: Patients who underwent open surgical repair (OSR) and endovascular aneurysm repair (EVAR) for infrarenal AAA were identified in National Surgical Quality Improvement Program (NSQIP) targeted databases from 2012 to 2021. Anemia was defined as preoperative hematocrit less than 39% in males and 36% in females. Multivariable logistic regression was used to compare 30-day perioperative outcomes between anemic and non-anemic patients, adjusting for demographics, comorbidities, indications, aneurysm extents, operation time, and surgical approaches. RESULTS: There were 408 (22.13%) anemic and 1436 (77.88%) non-anemic patients who underwent OSR for non-ruptured AAA, while 3586 (25.20%) patients with and 10,644 (74.80%) without anemia underwent EVAR. In both OSR and EVAR, anemic patients had higher risks of bleeding requiring transfusion (OSR, aOR = 2.446, p < .01; EVAR, aOR = 3.691, p < .01), discharge not to home (OSR, aOR = 1.385, p = .04; EVAR, aOR = 1.27, p < .01), and 30-day readmission (OSR, aOR = 1.99, p < .01; EVAR, aOR = 1.367, p < .01). Also, anemic patients undergoing OSR had higher pulmonary events (aOR = 2.192, p < .01), sepsis (aOR = 2.352, p < .01), and venous thromboembolism (aOR = 2.913, p = .01), while in EVAR, anemic patients had higher mortality (aOR = 1.646, p = .01), cardiac complications (aOR = 1.39, p = .04), renal dysfunction (aOR = 1.658, p = .02), and unplanned reoperation (aOR = 1.322, p = .01). Moreover, in both OSR and EVAR, anemic patients had longer hospital length of stay (p < .01). CONCLUSION: In OSR and EVAR, preoperative anemia was independently associated with worse 30-day outcomes. Preoperative anemia could be a useful marker for risk stratification for patients undergoing infrarenal AAA repair.

Effect of Chronic Kidney Disease on 30-Day Outcomes in Endovascular Repair of Complex Abdominal Aortic Aneurysm.

BACKGROUND: Chronic kidney disease (CKD) has been identified as an independent predictor of poorer long-term prognosis after endovascular aneurysm repair (EVAR) for complex abdominal aortic aneurysm (AAA). However, its impact on short-term perioperative outcomes is conflicting, which can be important for preoperative risk stratification. This study aimed to evaluate the 30-day outcomes of patients with CKD following non-ruptured complex EVAR in a national registry. METHODS: Patients who had EVAR for complex AAA were identified in ACS-NSQIP targeted database from 2012-2022. Complex AAA included juxtarenal, suprarenal, or pararenal proximal extent, Type IV thoracoabdominal aneurysm, and/or aneurysms treated with Zenith Fenestrated endograft. Exclusion criteria included age<18 years, ruptured AAA, acute intraoperative conversion to open, emergency presentation, and dialysis. Multivariable logistic regression was used to compare 30-day postoperative outcomes of CKD and non-CKD patients, where demographics, baseline characteristics, aneurysm diameter, distant aneurysm extent, anesthesia, and concomitant procedures were adjusted. RESULTS: There were 695 (39.33%) and 1072 (60.67%) patients with and without CKD, respectively, who underwent EVAR for complex AAA. Patients with and without CKD have comparable 30-day mortality (aOR = 1.165, 95 CI = 0.646-2.099, P = 0.61). However, CKD patients had a higher risk of renal complications (aOR = 2.647, 95 CI = 1.399-5.009, P < 0.01) including higher progressive renal insufficiency (aOR = 3.707, 95 CI = 1.329-10.338, P = 0.01) and acute renal failure requiring renal replacement therapy (aOR = 2.533, 95 CI = 1.139-5.633, P = 0.02). All other 30-day outcomes were comparable between CKD and non-CKD patients. CONCLUSION: Patients with CKD had similar 30-day mortality and morbidity rates but a higher risk of postoperative renal complications. Therefore, meticulous preoperative planning and postoperative management, which may include optimal hydration, appropriate contrast use, and close renal function monitoring, are essential for patients with CKD after complex EVAR.

The association of chronic obstructive pulmonary disease and 30-day outcomes of infrainguinal bypass surgery: A propensity-score matching study.

BACKGROUND: Infrainguinal bypass surgery is an effective treatment for peripheral artery disease (PAD). While chronic obstructive pulmonary disease (COPD) has been linked to heightened risks of mortality and morbidity in major surgery, a thorough investigation into COPD's impact on infrainguinal bypass outcomes remained underexplored. Thus, this study aimed to assess the 30-day outcomes for COPD patients undergoing infrainguinal bypass surgery. METHODS: COPD and non-COPD patients who underwent infrainguinal bypass were identified in American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2011 to 2022. Patients of age<18 were excluded. A 1:1 propensity-score matching was used to match demographics, baseline characteristics, symptomatology, procedure, conduit, and anesthesia. Thirty postoperative outcomes were compared. RESULTS: There were 3,183 (12.64%) and 22,004 (87.36%) patients with and without COPD, respectively, who underwent infrainguinal bypass. COPD patients had a higher comorbid burden. After propensity-score matching, COPD patients had higher sepsis (3.55% vs 2.42%, p = 0.01), wound complications (18.94% vs 16.40%, p = 0.01), and 30-day readmission (18.00% vs 14.92%, p < 0.01). However, COPD and non-COPD patients had comparable 30-day mortality (2.54% vs 2.67%, p = 0.81), and organ system complications including cardiac (3.58% vs 3.99%, p = 0.43), pulmonary (3.96% vs 3.20%, p = 0.12), and renal complications (1.70% vs 1.82%, p = 0.78). Limb-specific outcomes including major amputation (2.95% vs 2.50%, p = 0.30), untreated loss of patency (1.85% vs 1.38%, p = 0.16), and patent graft (98.24% vs 98.65%, p = 0.27) were also comparable between the cohorts. CONCLUSION: While COPD might be associated with the development of PAD due to potentially shared pathophysiology, it may not be an independent risk factor for the major 30-day outcomes in infrainguinal bypass surgery.

Prophylactic muscle flaps in high-risk-for-poor-healing patients with prosthetic bypasses increases deep wound complications.

BACKGROUND: Incisional complications of groin after inflow or infrainguinal bypasses with prosthetic conduits can result in major morbidities that require reoperation, infected graft removal, and limb loss. Muscle flaps are typically performed to treat groin wound complications, but they are also done prophylactically at the time of index procedures in certain high-risk-for-poor-healing patients to mitigate anticipated groin wound complications. We used a nationwide multi-institutional database to investigate outcomes of prophylactic muscle flaps in high-risk patients who underwent prosthetic bypasses involving femoral anastomosis. METHODS: We utilized ACS-NSQIP database 2005-2021 to identify all elective inflow and infrainguinal bypasses that involve femoral anastomoses. Only high-risk patients for poor incisional healing who underwent prosthetic conduit bypasses were selected. A 1:3 propensity-matching was performed to obtain two comparable studied groups between those with (FLAP) and without prophylactic muscle flaps (NOFLAP) based on demographics and comorbidities. 30-day postoperative outcomes were compared. RESULTS: Among 35,011 NOFLAP, 990 of them were propensity-matched to 330 FLAP. There was no significant difference in 30-day mortality, MACE, pulmonary, or renal complications. FLAP was associated with higher bleeding requiring transfusion, longer operative time, and longer hospital stay. FLAP also had higher overall wound complications (15.2% vs. 10.6%; p = 0.03), especially deep incisional infection (4.9% vs. 2.4%; p = 0.04). CONCLUSION: Prophylactic muscle flap for prosthetic bypasses involving femoral anastomosis in high-risk-for-poor-healing patients does not appear to mitigate 30-day wound complications. Caution should be exercised with this practice and more long-term data should be obtained to determine whether prophylactic flaps decrease the incidence of graft infection.

Prior abdominal surgery is not associated with 30-day mortality or morbidities after endovascular repair of complex abdominal aortic aneurysm.

BACKGROUND: Prior abdominal surgery (PAS) has the potential to affect outcomes of abdominal aortic aneurysm (AAA) repair. Recently, endovascular aneurysm repair (EVAR) has been expanded among patients with complex AAA, which involves visceral branches in the upper abdominal aortic. However, outcomes of EVAR for complex AAA in patients with PAS have not been examined. This study aimed to investigate the impact of PAS on 30-day outcomes in EVAR for complex AAA. METHODS: Patients who underwent EVAR for complex AAA were identified in ACS-NSQIP targeted database from 2012 to 2022. Complex AAA was defined as juxtarenal, suprarenal, or pararenal proximal extent, Type IV thoracoabdominal aneurysm, or aneurysms treated with Zenith Fenestrated endograft. Patients with age less than 18 years, ruptured AAA with or without hypotension, acute intraoperative conversion to open, and emergency presentation were excluded. Multivariable logistic regression was used to compare 30-day postoperative outcomes of patients with and without PAS. Demographics, baseline characteristics, aneurysm diameter, indication for surgery, proximal and distant aneurysm extent, anesthesia, and concomitant procedures were adjusted. RESULTS: There were 515 (28.34%) and 1302 (71.66%) patients with and without PAS, respectively, who underwent EVAR for complex AAA. Patients with and without PAS had comparable 30-day mortality (3.11% vs 3.00%, aOR = 0.766, 95 CI = 0.407-1.442, p = .41). Organ system complications including cardiac complications, stroke, pulmonary complications, and renal complications were comparable between patients with and without PAS. All other 30-day outcomes were similar between groups. However, patients with PAS had higher 30-day readmission rate (11.65% vs 7.14%, aOR = 1.634, 95 CI = 1.145-2.331, p = .01). CONCLUSION: While PAS has high prevalence among patients undergoing EVAR for complex AAA, it does not impact 30-day mortality and morbidities. Thus, EVAR for complex AAA can be considered safe for patients with PAS in terms of short-term outcomes, despite the long-term prognosis in these patients being needed in further studies.

Goals, Structure and Financing of Surgical Residency Training: A Subcommittee Report of the Blue Ribbon Committee II.

OBJECTIVE: As part of the Blue Ribbon Committee II, review current goals, structure and financing of surgical training in Graduate Medical Education (GME) and recommend needed changes. SUMMARY BACKGROUND DATA: Surgical training has continually undergone major transitions with the 80-hour work week, earlier specialization (vascular, plastics and cardiovascular) and now entrustable professional activities (EPAs) as part of competency based medical education (CBME). Changes are needed to ensure the efficiencies of CBME are utilized, that stable graduate medical education funding is secured, and that support for surgeons who teach is made available. METHODS: Convened subcommittee discussions to determine needed focus for recommendations. RESULTS: Five recommendations are offered for changes to GME financing, incorporation of CBME, and support for educators, students and residents in training. CONCLUSIONS: Changes in surgical training related to CBME offer opportunity for change and innovation. Our subcommittee has laid out a potential path forward for improvements in GME funding, training structure, compensation of surgical educators, and support of students and residents in training.

Locoregional Anesthesia Has Lower Risks of Cardiac Complications Than General Anesthesia After Prolonged Endovascular Repair of Abdominal Aortic Aneurysms.

OBJECTIVES: Although general anesthesia is the primary anesthesia in endovascular aneurysm repair (EVAR), some studies suggest locoregional anesthesia could be a feasible alternative for eligible patients. However, most evidence was from retrospective studies and was subjected to an inherent selection bias that general anesthesia is often chosen for more complex and prolonged cases. To mitigate this selection bias, this study aimed to compare 30-day outcomes of prolonged, nonemergent, intact, infrarenal EVAR in patients undergoing locoregional or general anesthesia. In addition, risk factors associated with prolonged operative time in EVAR were identified. DESIGN: Retrospective large-scale national registry study. SETTING: American College of Surgeons National Surgical Quality Improvement Program targeted database from 2012 to 2022. PARTICIPANTS: A total of 4,075 out of 16,438 patients (24.79%) had prolonged EVAR. Among patients with prolonged EVAR, 324 patients (7.95%) were under locoregional anesthesia. There were 3,751 patients (92.05%) under general anesthesia, and 955 of them were matched to the locoregional anesthesia cohort. INTERVENTIONS: Patients undergoing infrarenal EVAR were included. Exclusion criteria included age <18 years, emergency cases, ruptured abdominal aortic aneurysm, and acute intraoperative conversion to open. Only cases with prolonged operative times (>157 minutes) were selected. A 1:3 propensity-score matching was used to address demographics, baseline characteristics, aneurysm diameter, distant aneurysm extent, and concomitant procedures between patients under locoregional and general anesthesia. Thirty-day postoperative outcomes were assessed. Moreover, factors associated with prolonged EVAR were identified by multivariate logistic regression. MEASUREMENTS AND MAIN RESULTS: Except for general anesthesia contraindications, patients undergoing locoregional or general anesthesia exhibited largely similar preoperative characteristics. After propensity-score matching, patients under locoregional and general anesthesia had a lower risk of myocardial infarction (0.93% v 2.83%, p = 0.04), but comparable 30-day mortality (3.72% v 2.72%, p = 0.35) and other complications. Specific concomitant procedures, aneurysm anatomy, and comorbidities associated with prolonged EVAR were identified. CONCLUSIONS: Locoregional anesthesia can be a safe and effective alternative to general anesthesia, particularly in EVAR cases with anticipated complexity and prolonged operative times, as it offers the potential benefit of reduced cardiac complications. Risk factors associated with prolonged EVAR can aid in preoperative risk stratification and inform the decision-making process regarding anesthesia choice.

Letter re: Misidentification of Transcarotid Artery Revascularization by Current Procedural Terminology.

In this letter, we discussed the selection of patients undergoing Transcarotid Artery Revascularization (TCAR) using the Current Procedural Terminology (CPT) codes. We examined a previous study using CPT code 37215 to identify TCAR cases using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. As an ACS-NSQIP participating site, we have complete access to the ACS-NSQIP database, and we performed a more in-depth examination of the method. We found significant discrepancies in the method described and conclude that it is methodologically flawed to use CPT code 37215 to differentiate TCAR cases. This study not only re-evaluates the validity of the previous study but also has the potential to prevent other researchers from employing the erroneous methodology for TCAR selection using the CPT code, which is one of the most widely used standardizations of medical communication for surgical procedures. This is particularly pertinent given the recent "TCAR revolution", where significant attention has been focused on TCAR.

The 5-Factor Modified Frailty Index is a Succinct yet Effective Predictor of Adverse Outcomes in Patients Undergoing Open Surgery for Abdominal Aortic Aneurysm.

BACKGROUND: Frailty is an age-related, clinically recognizable state marked by increased susceptibility. The 5-item Modified Frailty Index (mFI-5) offers a concise assessment of frailty and has demonstrated its efficacy in various surgical fields. While the mFI-5 has been validated for endovascular aneurysm repair for abdominal aortic aneurysm (AAA), its applicability in open surgical repair (OSR) for AAA remains largely unexplored. This study sought to evaluate the utility of mFI-5 in predicting 30-day outcomes following OSR for AAA. METHODS: Patients underwent OSR for AAA were identified in American College of Surgeons National Surgical Quality Improvement Program-targeted database from 2012 to 2021. Patients were stratified into 3 cohorts: mFI-5 score of 0 (control), 1, and 2+. Multivariable logistic regression was used to compare 30-day perioperative outcomes between frail patients and controls adjusting preoperative variables with P value <0.1. RESULTS: Of the 5,249 patients who underwent OSR for AAA, 1,043 were controls, 2,938 had an mFI-5 score of 1 and 1,268 had an mFI-5 score of 2+. When compared to the control group, patients with an mFI-5 = 1 were more likely to have pulmonary events (adjusted odds ratio (aOR) = 1.452, P < 0.01), bleeding events (aOR = 1.33, P < 0.01), wound complications (aOR = 2.214, P < 0.01), ischemic colitis (aOR = 1.616, P = 0.01), and unplanned reoperation (aOR = 1.292, P = 0.04). Those with an mFI-5 = 2+ demonstrated higher risks of mortality (aOR = 1.709, P < 0.01), major adverse cardiovascular events (aOR = 1.347, P = 0.04), pulmonary events (aOR = 2.045, P < 0.01), renal dysfunction (aOR = 1.568, P < 0.01), sepsis (aOR = 1.587, P = 0.01), bleeding events (aOR = 1.429, P < 0.01), wound complications (aOR = 2.338, P < 0.01), ischemic colitis (aOR = 1.775, P = 0.01), unplanned reoperation (aOR = 1.445, P = 0.01), operation over 4 hours (aOR = 1.34, P < 0.01), length of stay over 7 days (aOR = 1.324, <0.01), discharge not to home (aOR = 1.547, P < 0.01), 30-day readmission (aOR = 1.657, P = 0.01). CONCLUSIONS: The mFI-5 emerges as a succinct yet effective indicator of frailty for patients undergoing OSR for AAA. Especially, an mFI-5 score of 2+ is linked with increased 30-day mortality and complications. As such, mFI-5 can be used as a valuable screening tool for frailty in patients undergoing OSR for AAA.

Acute Intraoperative Conversion from Endovascular to Open vs Planned Open Operation for Abdominal Aortic Aneurysm: A Propensity-Score Matched Study from the American College of Surgeons NSQIP-Targeted Database.

BACKGROUND: Evaluating outcomes for acute intraoperative conversion to open surgery during endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) was difficult due to low incidence. This study aimed to compare 30-day outcomes between patients with acute intraoperative conversion during EVAR and planned open surgery, and to identify risk factors associated with acute conversion. STUDY DESIGN: Patients who underwent EVAR or planned open AAA repair were identified in American College of Surgeons NSQIP-targeted databases from 2012 to 2021. Patients with acute intraoperative conversion during EVAR were selected. A 1:3 propensity-score matching was used to match demographics, baseline characteristics, surgical indications, aneurysm size and extent, and emergency cases between the conversion open and planned open groups. Thirty-day postoperative outcomes were assessed. RESULTS: Of 20,566 EVAR cases, 177 (0.86%) had acute intraoperative conversion to open surgery. The conversion open group was matched to 504 of 5,249 planned open patients. Conversion open and planned open groups had comparable 30-day mortality (23.43% vs 17.46%, p = 0.09) and organ system complications, including major adverse cardiovascular event (14.86% vs 10.71%, p = 0.17), pulmonary complications (17.71% vs 24.01%, p = 0.09), and renal complications (8.57% vs 11.11%, p = 0.39). The conversion open group had lower bleeding requiring transfusion (48.57% vs 75.60%, p < 0.01), shorter operation time (p < 0.01), and shorter length of stay (p < 0.01). Other postoperative outcomes did not differ. Risk factors associated with acute intraoperative conversion included ruptured aneurysm with or without hypotension. Protective factors included hypertension and aortic distal aneurysm extent. CONCLUSIONS: Although this study does not endorse a universal "EVAR first" strategy for all patients with AAA, EVAR can be attempted first in eligible patients with AAA. Even when EVAR is unsuccessful, intraoperative conversion to open surgery still appears to be safe compared with planned open repair.

The 5-Factor Modified Frailty Index is a Concise and Effective Predictor of 30-Day Adverse Outcomes in Carotid Endarterectomy.

INTRODUCTION: Frailty is a clinically identifiable condition characterized by heightened vulnerability. The 5-item Modified Frailty Index provides a concise calculation of frailty that has proven effective in predicting adverse perioperative outcomes across a variety of surgical disciplines. However, there is a paucity of research examining the validity of 11-item Modified Frailty Index (mFI-5) in carotid endarterectomy (CEA). This study aimed to investigate the association between mFI-5 and 30-day outcomes of CEA. METHODS: Patients underwent CEA were identified from American College of Surgeons National Surgical Quality Improvement Program targeted database from 2012 to 2021. Patients with age<18 were excluded. Patients were stratified into four cohorts based on their mFI-5 scores: 0, 1, 2, or 3+. Multivariable logistic regression was used to compare 30-day perioperative outcomes adjusting for preoperative variables with P value<0.1. RESULTS: Compared to controls (mFI-5 = 0), patients mFI-5 = 1 had higher risk of stroke (adjusted odds ratio [aOR] = 1.333, P = 0.02), unplanned operation (aOR = 1.38, P < 0.01), and length of stay (LOS) > 7 days (aOR = 0.814, P < 0.01). Patients with mFI-5 = 2 had higher stroke (aOR = 1.719, P < 0.01), major adverse cardiovascular events (MACE) (aOR = 1.315, P = 0.01), sepsis (aOR = 2.243, P = 0.01), discharge not to home (aOR = 1.200, P < 0.01), 30-day readmission (aOR = 1.405, P < 0.01). Compared with controls, patients with mFI-5≥3 had higher mortality (aOR = 1.997 P = 0.02), MACE (aOR = 1.445, P = 0.03), cardiac complications (aOR = 1.901, P < 0.01), pulmonary events (aOR = 2.196, P < 0.01), sepsis (aOR = 3.65, P < 0.01), restenosis (aOR = 2.606, P = 0.02), unplanned operation (aOR = 1.69, P < 0.01), LOS>7 days (aOR = 1.425, P < 0.01), discharge not to home (aOR = 2.127, P < 0.01), and 30-day readmission (aOR = 2.427, P < 0.01). CONCLUSIONS: The mFI-5 is associated with 30-day mortality and complications including stroke, MACE, cardiac complications, pulmonary complications, sepsis, and restenosis. Additionally, elevated mFI-5 scores correlate with an increased likelihood of unplanned operations, extended LOS, discharge to facilities other than home, and 30-day readmissions, all of which could negatively impact long-term prognosis. Therefore, mFI-5 can serve as a concise yet effective metric of frailty in patients undergoing CEA.

Development of a comorbidity index for patients undergoing abdominal aortic aneurysm repair.

BACKGROUND: Endovascular aneurysm repair (EVAR) and open surgical repair (OSR) are two modalities to treat patients with abdominal aortic aneurysm (AAA). Alternative to individual comorbidity adjustment, a summary comorbidity index is a weighted composite score of all comorbidities that can be used as standard metric to control for comorbidity burden in clinical studies. This study aimed to develop summary comorbidity indices for patients who underwent AAA repair. METHODS: Patients who went under EVAR or OSR were identified in National Inpatient Sample (NIS) between the last quarter of 2015 to 2020. In each group, patients were randomly sampled into experimental (2/3) and validation (1/3) groups. The weights of Elixhauser comorbidities were determined from a multivariable logistic regression and single comorbidity indices were developed for EVAR and OAR groups, respectively. RESULTS: There were 34,668 patients underwent EVAR (2.19% mortality) and 4792 underwent OSR (10.98% mortality). Both comorbidity indices had moderate discriminative power (EVAR c-statistic, 0.641; 95% confidence interval [CI], 0.616-0.665; OSR c-statistic, 0.600; 95% CI, 0.563-0.630) and good calibration (EVAR Brier score, 0.021; OSR Brier score, 0.096). The indices had significantly better discriminative power (DeLong P <.001) than the Elixhauser Comorbidity Index (ECI) (EVAR c-statistic, 0.572; 95% CI, 0.546-0.597; OSR c-statistic, 0.502; 95% CI, 0.472-0.533). For internal validation, both indices had similar performance compared with individual comorbidity adjustment (EVAR DeLong P = .650; OSR DeLong P = .431). These indices demonstrated good external validation, exhibiting comparable performance to their respective validation groups (EVAR DeLong P = .891; OSR DeLong P = .757). CONCLUSIONS: ECI, the comorbidity index formulated for the general population, exhibited suboptimal performance in patients who underwent AAA repair. In response, we developed summary comorbidity indices for both EVAR and OSR for AAA repair, which were internally and externally validated. The EVAR and OSR comorbidity indices outperformed the ECI in discriminating in-hospital mortality rates. They can standardize comorbidity measurement for clinical studies in AAA repair, especially for studies with small samples such as single-institute data sources to facilitate replication and comparison of results across studies.

Comparative assessment of racial disparity in 30-day outcomes for Asian Americans undergoing carotid endarterectomy.

OBJECTIVE: Carotid endarterectomy (CEA) is an effective treatment for carotid stenosis. All previous studies on racial disparity of CEA outcomes omitted Asian Americans. This study aimed to address this gap by investigating racial disparities in 30-day outcomes following CEA among Asian Americans. METHODS: Asian American and Caucasian patients who underwent CEA were identified in the American College of Surgeons National Surgical Quality Improvement Program targeted database from 2011 to 2021. Patients with age less than 18 years old were excluded. Patients with symptomatic and asymptomatic carotid stenosis were examined separately. A 1:5 propensity-score matching was used to address preoperative differences. Thirty perioperative outcomes were assessed. RESULTS: There were 380 Asian Americans (2.27%) and 13,250 Caucasians (79.18%) with symptomatic carotid stenosis who underwent CEA. Also, 289 Asian Americans (1.40%) and 18,257 Caucasians (88.14%) with asymptomatic carotid stenosis had CEA. Asian Americans undergoing CEA presented with higher comorbid burdens and more severe symptomology. Also, asymptomatic Asian Americans were more likely to undergo surgeries for mild stenosis (<50%), which is not in line with practice guidelines. After 1:5 propensity-matching, all symptomatic Asian Americans were matched to 1550 Caucasian patients, and all asymptomatic Asian Americans were matched to 1445 Caucasians; preoperative differences were addressed. Asian Americans exhibited low overall 30-day mortality (symptomatic, 1.61%; asymptomatic, 0.35%) and stroke (symptomatic, 2.26%; asymptomatic, 0.69%). All perioperative outcomes were comparable to Caucasians, with the exception that Asian Americans experienced longer operation times. CONCLUSIONS: Evidence suggested that Asian Americans with asymptomatic stenosis were underrepresented in CEA. After propensity-score matching, Asian Americans demonstrated comparable 30-day outcomes to Caucasians. These suggest that, when afforded equal access to quality health care, CEA serves as an effective treatment for carotid stenosis among Asian Americans. Therefore, efforts may be aimed at addressing health care access, potentially in the screening for asymptomatic carotid stenosis in Asian Americans. This would ensure they have equitable benefits from CEA. Nevertheless, the exact preoperative differences and long-term CEA outcomes in Asian Americans should warrant further examination in future studies.

AI-Powered Chatbots in Medical Education: Potential Applications and Implications.

Artificial intelligence (AI) is anticipated to have a considerable impact on the routine practice of medicine, spanning from medical education to clinical practice across specialties and, ultimately, patient care. With the imminent widespread adoption of AI in medical practice, it is imperative that medical schools adapt to the use of these advanced technologies in their curriculum to produce future healthcare professionals who can seamlessly integrate these tools into practice. Chatbots, AI systems programmed to process and generate human language, are currently being evaluated for various tasks in medical education. This paper explores the potential applications and implications of chatbots in medical education, specifically in learning and research. With their capability to summarize, simplify complex concepts, automate the creation of memory aids, and serve as an interactive tutor and point-of-care medical reference, chatbots have the potential to enhance students' comprehension, retention, and application of medical knowledge in real-time. While the integration of AI-powered chatbots in medical education presents numerous advantages, it is crucial for students to use these tools as assistive tools rather than relying on them entirely. Chatbots should be programmed to reference evidence-based medical resources and produce precise and trustworthy content that adheres to medical science standards, scientific writing guidelines, and ethical considerations.

Dependent functional status rather than age is a better predictor of adverse outcomes after excision of an infected abdominal aortic graft.

OBJECTIVE: The optimal management of infected abdominal aortic grafts is complete surgical excision plus in situ or extra-anatomic revascularization in patients who can tolerate this morbid operation. In addition to using age and the presence of comorbidities for risk assessment, physicians form a global clinical impression when deciding whether to offer excision or to manage conservatively. Functional status is a distinct objective measure that can inform this decision. This study examines the relative impact of age and functional status on outcomes of infected abdominal aortic graft excision to guide surgical decision-making. METHODS: Current Procedural Terminology code 35907 was used to identify patients undergoing excision of infected abdominal aortic graft in the 2005 to 2017 American College of Surgeons - National Surgical Quality Improvement Program (NSQIP) database. Patients were stratified by the upper age quartile (75 years old) as a cutoff, and then by functional status, independent vs dependent (as defined by NSIQIP). The patients were then stratified into four groups: Younger (<75)/Independent, Younger (<75)/Dependent, Older (≥75)/Independent, and Older (≥75)/Dependent. Outcomes measured included 30-day mortality and major organ-system dysfunction. RESULTS: There were 814 patients who underwent infected abdominal aortic graft excision: 508 patients (62%) were Younger/Independent, 89 patients (11%) were Younger/Dependent, 176 patients (22%) were Older/Independent, and 41 patients (5%) were Older/Dependent. There was no statistically significant difference in 30-day mortality for Younger/Dependent (odds ratio [OR], 1.66; 95% confidence interval [CI], 0.90-3.09; P = .536) or Older/Independent (OR, 1.31; 95% CI, 0.78-2.19; P = .311) patients when compared with Younger/Independent patients, which suggests that neither old age nor dependent functional status by itself adversely affects mortality. However, when both factors were present, Older/Dependent patients had three times higher mortality when compared with Younger/Independent patients (41.5% vs 13.4%, respectively; OR, 3.13; 95% CI, 1.46-6.71; P = .003). Furthermore, as long as patients presented with independent functional status, old age by itself did not adversely affect major organ-system dysfunction (ORs for Older/Independent vs Younger/Independent were 0.76 [P = .454], 1.04 [P = .874], and 0.90 [P = .692] for cardiac, pulmonary, and renal complications, respectively). On the contrary, even in younger patients, dependent functional status was significantly associated with higher pulmonary complications (Younger/Dependent vs Younger/Independent: OR, 2.22; 95% CI, 1.33-3.73; P = .002) and higher rates of unplanned reoperation (OR, 2.67; 95% CI, 1.62-4.41; P < .0001). CONCLUSIONS: Dependent functional status has significant association with adverse outcomes after excision of infected abdominal aortic grafts, whereas old age alone does not. Therefore, this procedure could be considered in appropriately selected elderly patients with otherwise good functional status. However, caution should be applied in dependent patients regardless of age due to the risk of pulmonary complications.

A Novel Angiography Scoring System Predicts Improvement After Isolated Common Femoral Endarterectomy With Profundaplasty.

BACKGROUND: Numerous angiography-based peripheral arterial disease classification schemes have been developed to stratify severity of preoperative patient disease, but few studies have correlated angiography-based anatomic classification schemes to postoperative outcomes. This study examined whether a proposed pre-operative angiography scoring system was predictive of outcomes after isolated common femoral endarterectomy with profundaplasty (CFEP). METHODS: A retrospective review was conducted of patients treated with isolated CFEP for claudication and/or rest pain at a single institution from 2016-19. Pre-operative angiograms were assessed quantitatively by 4 blinded surgeons across 3 domains: profunda stenosis, profunda disease length, and outflow disease severity. Table I describes the proposed angiography scoring system. Internal consistency reliability of rater scores was calculated using Cronbach alpha. Outcomes included clinical improvement, further interventions, major amputations, mortality, and mean increase in ankle-brachial index (ABI) at 30 days, and 6 months. McNemar tests, between-group t-tests, Pearson correlations, and linear regression were used. RESULTS: Clinical Outcomes 88% of patients (n = 22) had clinical improvement at 30 days; the remaining 12% of patients (n = 3) required further interventions. One patient (4%) required major amputation between 30 days and 6 months for recurrence of rest pain that had initially resolved after isolated CFEP. There was 0% mortality during the study period. Mean ABI increased by 0.15 ± 0.21 at 30 days, and by 0.06 ± 0.21 at 6 months. Angiography Scoring System Profunda stenosis score was associated with clinical improvement at 6 months (P = 0.04). A profunda stenosis score of ≥2.6 was strongly associated with 6-month clinical improvement (64% of those ≥ 2.6 improved, versus 15% of those <2.6, P = 0.15). Profunda stenosis score was associated with ABI improvement at 30 days (r = 0.73, P = 0.01) and 6 months (r = 0.82, P = 0.007). Profunda disease length score was associated with clinical improvement at 30 days (P = 0.002). 100% of patients with a profunda disease length score of ≥1.5 clinically improved at 30 days, versus 67% of those with <1.5 (P = 0.04). Angiography scores were not found to be associated with further intervention, major amputation, or mortality. Cronbach alpha for profunda stenosis, profunda disease length, and outflow severity scores were 0.90, 0.90, and 0.79, respectively, indicating strong internal consistency. CONCLUSIONS: This institutional angiography scoring system successfully predicts clinical improvement following CFEP.  Higher profunda stenosis and profunda disease length scores were most predictive of operative success within 6 months. Future validation studies will investigate these outcomes in a larger population, and over a longer period.